Bazinet, Corina Farm VS.I• NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after ire FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town _ Registered No.._... .._.; .....__
.�!d... Village
V�./...�:.
Dist. No:.:.�.�:I....County. .�.�5.1� or City
16
(If city, give street address)
Name 9f deceased.,. ...��1,4:/ Veteran
r d Single, marri , widowed, (If veteran, give name War)
S dolor. !! 1ri..or divorced (wnte the word).. Date of Death 2 — �" 19.. ..l
Age....'7 Y ars Months-,) Days Birthplace: tt. y• ••
Cause of D GCertificatewas signed ..... M.D.
Address.........:.:��� p� , j -Place of Burial (or Removal) .Q-tnA-!4rs.... . .�fers,.e.0..�
(If body is to be to rarity ,g}ins ce later)
Cemetery.„ % G . cz . .. . . . Date o urial — , 7 19••s4•/
(If body i to temporarily hel 11 in space later)
The,Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num , on the basis f I HEREBY GRANT A PERMIT
✓r. me) (e res
the .'.. to hold temporaril and ' the body.
4 .ertaker versos basin charge of corpse) — fln r, qr erwise dispose of[state how])
Dated. ; • 19...4,.1. (Signed) J
Local Registrar
Permit s sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (eabject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was 19
(Interment or C ar6fnn)
(Name( f Cemetery, Crematorium, etc.)
1.1 Z
Section -- Lot No. Grave No.
LUl(Signed) . v F - 1 9 _
(Pe on in charge)
Address (� C
(-
Person in charge must return this Permit to / .:(
1 u
the Registrar of his District within SEVEN (7) DAYS /
from above date. If no person is in charge, the C
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.